Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial Jon S. Matsumura, MD,a Kevin T. Stroupe, PhD,b Frank A. Lederle, MD,c Tassos C. Kyriakides, PhD,d Ling Ge, MS,b and Julie A. Freischlag, MD,e for the Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group,* Madison, Wisc; Hines, Ill; Minneapolis, Minn; West Haven, Conn; and Baltimore, Md Objective: Prior analysis in the Open vs Endovascular Repair Veterans Affairs (VA) Cooperative Study (CSP #498) demonstrated that survival, quality of life, and total health care costs are not significantly different between the open and endovascular methods of repair of abdominal aortic aneurysm. The device is a major cost of this method of repair, and the objective of this study was to evaluate the costs of the device, abdominal aortic aneurysm repair, and total health care costs when different endograft systems are selected for the endovascular repair (EVR). Within each selected system, EVR costs are compared with open repair costs. Methods: The study randomized 881 patients to open (n [ 437) or EVR (n [ 444). Device selection was recorded before randomization; therefore, open repair controls were matched to each device cohort. Data were excluded for two lowvolume devices, implanted in only 13 individuals, leaving 423 control and 431 endovascular patients: 166 Zenith (Cook Medical, Bloomington, Ind), 177 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), and 88 AneuRx (Medtronic, Minneapolis, Minn). Mean device, hospitalization, and total health care costs from randomization to 2 years were compared. Health care utilization data were obtained from patients and national VA and Medicare data sources. VA costs were determined using methods previously developed by the VA Health Economics Resource Center. Non-VA costs were obtained from Medicare claims data and billing data from the patient’s health care providers. Results: Implant costs were 38% of initial hospitalization costs. Mean device (range, $13,600-$14,400), initial hospitalization (range, $34,800-$38,900), and total health care costs at 2 years in the endovascular (range, $72,400-$78,200) and open repair groups (range, $75,600-$82,100) were not significantly different among device systems. Differences between endovascular and corresponding open repair cohorts showed lower mean costs for EVR (range, $3200-$8300), but these were not statistically different. Conclusions: The implant costs of endovascular aneurysm repair are substantial. When evaluating total health care system expenditures, there is large individual variability in costs, and there is no significant difference at 2 years among systems or when an individual system is compared with open repair. (J Vasc Surg 2015;61:59-65.)
Efforts to contain health care costs have gained greater prominence, and physicians are in a pivotal role of determining which treatments their patients receive. Endovascular repair (EVR) of abdominal aortic aneurysms (AAAs) is particularly visible, with high volume and very high device cost. Victor Fuchs has stated,
From the Veterans Affairs Medical Centers at Madison,a Hines,b Minneapolis,c West Haven,d and Baltimore.e *Participants in the study group are listed in the Appendix (online only). This study was supported by the Cooperative Studies Program of the Department of Veterans Affairs (VA) Office of Research and Development, Washington, D.C. J.S.M. has received research grants from the National Institutes of Health. Author conflict of interest: J.S.M. has received research grants from Cook, Coviden, Abbott, W. L. Gore & Associates, and Endologics. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: Jon S. Matsumura, MD, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, G5/ 325 Clinical Science Center, 600 Highland Ave, Madison, WI 53792 (e-mail:
[email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.08.003
The role of new medical technology deserves special attention in thinking about future health care spending because biomedical innovations as a whole have been the primary source of both improvements in health and increasing expenditures. On the one hand, it is fiscally irresponsible to continue to accept innovations regardless of cost, even if they pass tests of safety and efficacydand it is particularly irresponsible when the interventions are provided at public expense. On the other hand, we must avoid an innovation policy that cuts off new interventions prematurely.1
Several randomized trials have demonstrated similar long-term survival and quality of life when AAAs are electively repaired by EVR or open methods.2-4 Comparisons of costs have been evaluated with contrasting results, with some studies showing cost-effectiveness of EVR, and others finding EVR was more costly.2,5-7 The Department of Veterans Affairs (VA) Open vs Endovascular Repair (OVER) trial (ClinicalTrials.gov number, NCT00094575) reported a comparison of costs at 2 years between EVR and open repair of AAA. Specifically, mean graft costs were higher with EVR ($14,052 vs $1363; P
